Capstone Outline –

Radiation therapy treatment of the prone breast using EZFluence: A case study

I. ABSTRACT
II. Introduction
A. Breast cancer remains the most commonly diagnosed cancer in women worldwide,
and the fifth leading cause of death from cancer overall.1
B. Since its inception, independent studies have recognized the benefits of whole breast
irradiation in the prone position as compared to the supine position; these benefits

include decreasing acute toxicity, cosmetic changes, risks of radiation‐induced lung

cancer, and cardiac toxicity.2 Other benefits for prone breast radiation therapy include
improved dose coverage, better homogeneity, less hotspots within treatment volume,
lower ipsilateral lung and heart dose, lower contralateral breast dose, and reduced
skin reactions.3
C. One new software has been developed, known as EZFluence, which is used to create
an optimal fluence pattern to generate a homogenous dose distribution for breast
radiation treatments.8
D. To date, there is very limited data demonstrating the benefits of EZFluence as
compared to manual field-in-field (FiF) techniques for supine and prone breast
patients.8
E. The purpose of this study will be to provide information which may help to improve
prone breast planning time, organ at risk (OAR) sparing, and overall dose uniformity
to the target.
III. Case Description
A. Patient Selection
1. Patient selection was based on various factors, and narrowed to a study group of 10
female individuals with breast cancer who met the criteria of having intact,
pendulous breasts (post-lumpectomy) without nodal involvement. Only patients
that were set up in the prone position, per the attending radiation oncologist’s
request, were included.
 A. The range of PTV size for our included patients was ____ cc; the mean
PTV size was ____ cc.
2. Planning was done retrospectively to include the whole affected breast to a dose of
42.56 Gy using both non-divergent medial and lateral 3-Dimensional Conformal
Radiation Therapy (3D CRT) tangential beams produced by manual FiF techniques
and EZFluence software (dose from any boost after the initial 42.56 Gy was not
included in this study).
3. All patients received a CT simulation with a GE Lightspeed 16 multi-slice CT
Scanner. All patients were setup in the prone position on a CDR Systems prone breast
board with their arms up prior to treatment planning. Breast borders and the
lumpectomy scar were delineated with radiopaque wire stickers per the radiation
oncologist. Alignment reference markers were used for positioning and subsequent
markings were placed for future set-up.
A. [Diagram of CT simulation setup devices / patient position
included here]
4. Patients in this study were all set-up in an identical fashion to that explained above;
patients set up in the supine position were excluded from this study.
B. Target Delineation
1. All target delineation was performed in Varian Medical Systems Eclipse Treatment
Planning System (TPS), version 13.7. Targets, which included the affected whole
breast of each patient, were delineated for treatment planning and were checked by
the attending physician to ensure accuracy and consistency. Target structures were
defined per the following:
A. Cavity: visible lumpectomy region as determined by the radiation
oncologist
B. PTV_Lumpectomy_4256: Cavity + 1.0cm margin
C. PTV_Eval: PTV_Lumpectomy_4256 cropped 0.5cm from skin and
cropped from muscles of the chest wall. Any portions of the cavity that
were removed by this method were added back into the PTV_Eval
volume.
 D. PTV_Breast: Entire breast volume as determined by the radiation
oncologist
E. PTV_Breast_Eval: PTV_Breast cropped 0.5cm from the skin
2. The general OAR for prone breast treatment planning were segmented as well,
which included the bilateral lungs, heart, liver, esophagus, and spinal cord.
Contouring of OAR was performed per RTOG contouring atlas recommendations.
C. Treatment Planning
1. Each of the 10 patients in this study was prescribed a radiation dose of 42.56 Gy
to the intact whole breast to be delivered in 16 fractions at 2.66 Gy per fraction.
2. Beam angles, collimator angles, and field sizes were determined by the radiation
oncologist
3. Isocenter was chosen by the attending radiation oncologist at the time of CT
simulation and was located at the approximate center of the breast volume (roughly
at the midpoint of the breast tissue external separation and in proximity of the chest
wall).
4. Two different 3D-CRT plans were created for each patient, one utilizing the
manual FiF technique and one running the EZFluence script. All plans were
constructed using opposed tangential field arrangements with 6 MV energy photon
beams without the use of bolus.
A. EZFluence plans were performed with a maximum number of segments
being 8 and the minimum number of Monitor Units (MU) per field being
4.
5. All plans were generated with the goal of achieving at least 95% of the whole
breast planning target volume (PTV) coverage with at least 95% of the prescription
dose. OAR and critical structure dose constraint objectives were also kept below
goal amounts. The treatment plan goal summary for the OAR and critical
structures were as follows: contralateral lung V(≥4 Gy) ≤ 10%, ipsilateral lung
V(≥16 Gy) ≤ 10%, V(≥8 Gy) ≤ 15%, V(≥4 Gy) ≤ 25%, contralateral breast Dmax
≤ 2.4 Gy, esophagus V(≥45 Gy) ≤ 33%, liver Dmean ≤ 2.8 Gy, spinal cord Dmax
≤50 Gy and heart Dmean ≤ 3.2 Gy and Dmax ≤ 16 Gy.
 5. Based on their research, Keenan et al5 found that a V105% of more than 30cc and
conventional fractionation have a strong indicator for acute skin toxicity in general
breast planning. For this reason, V105 was also criteria evaluated in this study
6. The initial dose was calculated using a grid size of 0.25 cm with the analytical
anisotropic algorithm (AAA) from Eclipse TPS. Plans not meeting the 95% PTV ≥
95% prescription dose objective, were optimized to ensure coverage and maintain
uniformity between plans.
7. Dose volume histograms (DVH) as well as DVH statistics tables were then
evaluated and planning measures compared. Values assessed were the amount of the
PTV receiving ≥ 95% of the prescribed dose, V105%, as well as dose to the bilateral
lungs, heart, liver, esophagus, and spinal cord.
D. Plan Analysis & Evaluation
1. The use of the EZFluence software script for prone breast radiotherapy planning
showed improvement in planning times and reduced the PTV volume receiving 105%
of prescribed dose. In addition, EZFluence produced similar and in some cases better
dose sparing to OAR as compared to manual FiF planning techniques.
2. Data collected from the plan for Patient 1 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 1 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
3. Data collected from the plan for Patient 2 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 2 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
4. Data collected from the plan for Patient 3 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 3 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
5. Data collected from the plan for Patient 4 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 4 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
6. Data collected from the plan for Patient 5 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 5 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
7. Data collected from the plan for Patient 6 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 6 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
8. Data collected from the plan for Patient 7 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 7 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
9. Data collected from the plan for Patient 8 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 8 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
10. Data collected from the plan for Patient 9 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 9 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
11. Data collected from the plan for Patient 10 showed a total planning time of ____
with the manual FiF technique as compared to _____ for the plan generated with the
EZFluence software script. The V105% for the EZFluence plan was _____, while
using the manual FiF technique was _____. The doses to the OAR and critical
planning structures were _____ (maximum, mean, and relevant dose to critical
structures), and the overall hotspot of each plan for Patient 10 was _____ and _____
for the EZFluence plan and the manual FiF technique plan respectively.
12. Plans generated with EZFluence had a _____ difference on the overall planning
time when compared to the traditional manual FiF technique. The average V105% for
the EZFluence plans was _____, while the manual FiF technique average V105% was
_____. PTV coverage was similar for both sets of plans, which was to be expected
since both plans were normalized so that the prescription covered 95% of the PTV
volume.
13. When comparing and contrasting the doses received by the OAR and critically
planning structures, one can see that _____.
14. The average global max hotspot for each plan produced with the help of
EZFluence was _____. The plans created with the manual FiF technique averaged a
global max hotspot of _____.
15. A secondary MU verification software, RadCalc, was utilized to evaluate all plans
within 3% accuracy.
 References
1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide:
Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer.
2015;136(5):E359-E386. https://dx.doi.org/10.1002/ijc.29210
2. Boute B, De Neve W, Speleers B, et al. Potential benefits of crawl position for prone
radiation therapy in breast cancer. J Appl Clin Med Phys. 2017;18(4):200–205.
https://dx.doi.org/10.1002/acm2.12118
3. Haffty, BG. Supine or prone breast radiation: Upsides and downsides. Int J Radiat Oncol
Biol Phys. 2018;101(3):510-512. https://dx.doi.org/10.1016/j.ijrobp.2018.03.023
4. Yoder T, Hsia AT, Xu Z, Stessin A, Ryu S. Usefulness of EZFluence software for
radiotherapy planning of breast cancer treatment. Med Dosim. 2019;S0958-3947(18):30137-
7. https://dx.doi.org/10.1016/j.meddos.2018.12.001
5. Keenan LG, Lavan N, Dunne M, McArdle O. Modifiable risk factors for acute skin toxicity
in adjuvant breast radiotherapy: Dosimetric analysis and review of the literature. Med
Dosim.2019;44(1):51-55. https://dx.doi.org/10.1016/j.meddos.2018.01.004
6. Olson KN. Improving treatment outcomes of breast radiation therapy: the prone position.
Radiat Therapist. 2014;23(1):21-26. https://web-b-ebscohost-
com.libweb.uwlax.edu/ehost/pdfviewer/pdfviewer?vid=7&sid=6c25b527-3254-4499-9769-
da885b9aa3d5%40sessionmgr102. Published Spring 2014. Accessed May 31, 2019.
7. Venkatesan K, Deshpande S, Anand V, et al. Comparison of heart and lung doses in deep
inspiration breath hold radiation therapy and prone position radiation therapy for whole
breast radiation therapy. Int J Radiat Oncol Biol Phys. 2018;102(3):489-490.
https://dx.doi.org/10.1016/j.ijrobp.2018.07.1393
8. Mak KS, Chen YH, Catalano PJ, et al. Dosimetric inhomogeneity predicts for long-term
breast pain after breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2014;93(5):1087-
1095. https://dx.doi.org/10.1016/j.ijrobp.2014.05.021
9. Hymas RV, Jawad MS, Mangona VS, et al. Dosimetric predictors of toxicity and cosmesis in
women treated with hypofractionated whole-breast irradiation. Int J Radiat Oncol Biol Phys.
2014;90(1):S270-S271. https://dx.doi.org/10.1016/j.ijrobp.2014.05.930